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Critical Elements of the Crisis Intervention Team Model of Jail Diversion: An Expert Survey

Alan B. McGuire, Ph.D.* and Gary R. Bond, Ph.D. y

The Crisis Intervention Team (CIT) model of jail diversion is a promising approach to addressing the over-involvement of people with mental illness with the criminal justice system. Despite its popularity and promising empirical support, the literature has yet to clarify CIT’s critical elements. The aim of this study was to assess the degree to which experts agreement on the importance and perceived implementation of the critical elements of CIT. Study 1 used a literature review to cull potential elements. Three experts familiar with the CIT model reviewed these elements. Study 2 utilized an online survey of 55 CIT co-ordinators/officers and published experts to assess agreement regarding importance and degree the element is implemented. A preliminary list of 36 elements was identified with a high level of expert agreement on their importance regarding importance and implementation. This study developed a preliminary list of elements of the CIT’s program. Further research should develop consensus, explore elements’ association with outcomes, and differentiate elements from those common to all jail diversion programs. Copyright # 2010 John Wiley & Sons, Ltd.

The over-involvement of people with mental illness in the criminal justice system, or

criminalization (Abramson, 1972) is a critical problem. For instance, Teplin (1990)

found schizophrenia and major affective disorders to be two to three times as prevalent

in the Cook County Jail than in the general population. Teplin (1984) previously

indicated criminalization begins with the interaction between police and people with

mental illness. Later research indicated police do not intentionally discriminate against

people with mental illness, but feel caught between protecting the consumer and society

in general (Cotton, 2004). The Crisis Intervention Team (CIT) model of jail diversion

attempts to improve this interaction.

The CIT model includes two collaborative components: (1) specially trained

criminal justice officers, and (2) a specialized crisis response site (SCRS; Dupont &

Cochran, 2002; Steadman et al., 2001). CIT officers are trained to assess and de-

escalate situations involving persons with mental illness and, if necessary, transport

them to the SCRS. SCRSs provide centralized drop-off points for police with ‘‘police-

friendly’’ policies that allow officers to quickly transfer the individual and return to their

patrol duties (Steadman, 2001).

Behavioral Sciences and the Law

Behav. Sci. Law 29: 81–94 (2011) Published online 21 June 2010 in Wiley Online Library

(wileyonlinelibrary.com) DOI: 10.1002/bsl.941

*Correspondence to: Alan B. McGuire, Ph.D., ACT Center of Indiana, Indiana University Purdue University Indianapolis, Department of Psychology, c/o Richard L. Roudebush VAMC, 1481 W. 10th St (11H), Room D6014, Indianapolis, IN 46202, U.S.A. E-mail: [email protected] y Department of Psychiatry, Dartmouth Medical School, Hanover, NH 03755-1404, U.S.A.

Preliminary studies of CIT programs yielded promising results regarding response

time, rates of arrest, and officer perceptions of CIT (Borum, Deane, Steadman, &

Morrissey, 1998; Steadman, Deane, Borum, & Morrissey, 2000). CIT officers also have

consistently shown an increased rate of transporting individuals to mental health

services. A large, multi-site study including two CIT programs (Lattimore et al., 2003)

showed diverted consumers spent more time in the community and indicated that CIT-

diverted individuals experience positive mental health and quality-of-life outcomes

(Broner, Lattimore, Cowell, & Schlenger, 2004).

However, results from different CIT sites have been inconsistent. Memphis and

Portland, the two sites in the multi-site study, differed in relation to various measures of

mental health and quality-of-life outcomes (Broner et al., 2004). A CIT program in Akron,

Ohio, showed substantially higher arrest rates than previously examined programs (Teller,

Munetz, Gil, & Ritter, 2006). The CIT programs examined in the aforementioned studies

differ substantially in the elements included. For instance, one program works in concert

with emergency medical services. Another utilizes a 24-hour community-based crisis center

rather than a psychiatric emergency room. Because these programs differ in relation to

substantive programmatic aspects, it is difficult to discern: (a) what ‘‘model’’ is being

examined, and (b) what elements are responsible for differing results.

Critical Elements

A critical step in validating a promising model is distilling its critical elements. This

process clarifies a model and facilitates the development of a fidelity scale (Bond et al.,

2000). Fidelity is the measurement of adherence to model principles. Mowbray, Holter,

Teague, and Bybee (2003) emphasized that without ensuring fidelity, studies lack

construct validity. Evans (2002) suggested a two-step process for defining critical

elements of a developing model: (1) a literature review to extract critical elements,

followed by (2) confirmation by expert agreement. Regarding the latter, Bond et al.

(2000) recommend self-administered questionnaires, which have been utilized

extensively (Evans, 2002; Marty, Rapp, & Carlson, 2001; Schaedle, McGrew, Bond,

& Epstein, 2002).

The current effort is the first to empirically examine the critical elements of CIT (or

any specific jail diversion program). Study 1 aimed to develop a list of potential elements

of CIT via a literature review and select expert feedback. Study 2 utilized an expert

survey to assess agreement and perceived degree of implementation of the elements

derived in Study 1.

STUDY 1: DEVELOPMENT OF PRELIMINARY ELEMENTS

Methods

The aim of Study I was to form a list of potential elements of the CIT model. Elements

were derived from a literature review and feedback from a select group of experts. The

Indiana University Purdue University Indianapolis institutional review board approved

the study.

82 A. B. McGuire and G. R. Bond

Sample

Participants in Study 1 were ‘‘select experts’’ who were willing to be involved more

extensively in the research. This group was a convenience sample selected based on

their availability and renown in the area. Select experts included two published experts

with over 25 years in the field and a senior CIT officer in a mid-sized midwestern city.

Procedures

Study 1 began with a review of the literature relevant to CIT. The investigator

conducted Medline and PsychInfo searches of the following two sets of terms: (1)

‘‘crisis intervention team’’, and (2) (‘‘jail diversion program’’ or ‘‘police’’ or ‘‘criminal

justice’’) AND (‘‘mental’’ or ‘‘schizophrenia’’). Results were limited to published books

and peer-reviewed journal articles pertinent to jail diversion programs and that

examined the CIT model. The first author searched for mention of any element of the

CIT program. Next, the select experts critiqued the preliminary list of CIT program

elements for appropriateness, wording, and grouping of the items.

Results

Table 1 contains a list of potential elements and sources citing these elements. Included

elements (excluding distracters, items intentionally not relevant to CIT and/or

components of different models used to avoid acquiescence bias) were cited by an

average of 4.40 sources (SD ¼ 3.27) and ranged from one to 14 citations. The mean number of citations per element differed by category: organization and collaboration

(M ¼ 3.00, SD ¼ 0.74), law enforcement (M ¼ 5.78, SD ¼ 3.87), and mental health (M ¼ 3.23, SD ¼ 2.62; F(2, 45) ¼ 4.59, p ¼ .02. Post-hoc comparisons using a Bonferroni adjustment did not yield significant differences between any pair of

categories.

STUDY 2: EXPERT AGREEMENT SURVEY

Methods

Sampling

Study 2 employed an iterative process in which experts were identified via multiple

sources and then asked to both participate and identify additional experts (Evans, 2002;

Hartford, Carey, & Mendonca, 2006). At each step, we sought two, partially

overlapping types of experts: published experts and CIT program co-ordinators/

officers. Published experts were authors or co-authors of the literature identified in

Study 1; the investigator was able to contact 36 out of 55 (65.5%) of these published

experts, including at least one author from all 17 publications reviewed.

The investigator used multiple strategies to identify CIT officers/co-ordinators. A

contact list from a previous survey of police-based diversion programs (Reuland, 2004)

Crisis Intervention Team model of jail diversion 83

Table 1. Possible elements of the Crisis Intervention Team (CIT) model and their sources

CIT elements Source

Philosophy and collaboration 1. Program co-ordinator 13, 16 2. Pre-booking 4, 10, 11, 17 3. Post-booking diversion (distracter) - 4. Jail is avoided 5, 8, 13 5. Charges avoided or reduced 5, 10, 11 6. Treatment mandated (distracter) – 7. Diversion for minor offenses 7, 10 8. Court-based diversion (distracter) –

lLaw enforcement roles/services CIT officer selection 9. Voluntary service 1, 3, 4, 7, 8, 13, 14, 15, 16, 17 10. Formal selection process 13, 16, 17 11. Officer’s record 7, 13, 16 12. Experienced officers 4, 7 13. Psychological testing (distracter) –

CIT Officer Training 14. Intensive training 3, 4, 5, 7, 8, 10, 11, 13, 14, 15, 16, 17 15. Training for dispatchers 13, 14, 16 16. Department-wide training (distracter) – 17. De-escalation 3, 4, 5, 7, 8, 11, 13, 14, 15, 16, 17 18. Persons with mental illness and family

member trainers 3, 5, 13, 14, 17

19. Mental health provider trainers 4, 5, 11, 13, 14, 16 20. Practical training 4, 8, 13, 14, 16, 17 21. Cross-training 6, 13

CIT Officer Roles 22. Specialized officers 1, 3, 4, 5, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17 23. Mental health officers (distracter) – 24. Specialized officers maintain patrol duties 3, 4, 5, 7, 8, 14, 16, 17 25. CIT officers function as a team 5, 14 26. On-scene disposition 3, 5, 10, 11, 12, 14 27. CIT officer is designated officer in

charge on mental health calls 4, 5, 7, 8, 17

28. CIT officer responds to all mental health calls 1, 3, 4, 7, 8, 9, 11, 15, 17 29. Specialized unit (distracter) – 30. 24/7 Coverage 3, 4, 5, 8, 13, 16 31. De-escalation 3, 4, 5, 7, 8, 11, 13, 14, 15, 16, 17 32. Transport to crisis center 3, 5, 8, 11, 12, 17 33. Role in civil commitment process 14 34. CIT officers serve jails/prisons (distracter) – 35. Leadership within agency 7 36. Command staff committed to effective response 14

Mental health services Specialized crisis response site (SCRS) 37. Rapid transfer of responsibility 1, 3, 6, 13, 14, 16 38. Legal grounds for detention 6 39. No-refusal policy 1, 3, 5, 6, 7, 13, 14 40. Crisis line 6 41. Referral to outpatient community providers 6, 7, 14 42. Specialized crisis response site 1, 5, 6, 7, 8, 10, 12, 13, 17 43. Services available 24 hour/7 days a week 8, 13, 14 44. Single point of entry 1, 6, 7, 14 45. Secure transportation 6 46. Ambulance service 6, 17 47. SCRS is a secure facility 6 48. No productivity standard 6

(Continues)

84 A. B. McGuire and G. R. Bond

provided some CIT program co-ordinators. We bolstered this initial list by searches of

online databases, general internet searches, and contact information from conferences and

other professional sources. Websites included the Ohio Criminal Justice Coordinating

Center for Excellence (http://www.neoucom.edu/CJCCOE/), the Consensus Project

(http://consensusproject.org), and the NAMI CIT Technical Assistance Center (http://

www.nami.orgv/Template.cfm?Section ¼ CIT2&Template¼ /TaggedPage/TaggedPage Display.cfm&TPLID ¼ 62&ContentID¼ 35547). In total, we invited 108 CIT officers/ co-ordinators during this wave.

We recruited additional participants by placing notices on LISTSERVs maintained

by The Consensus Project (Council of State Governments, 2002) and NAMI CIT

Technical Assistance Center. The announcements were posted in August (NAMI) and

September (Consensus Project) of 2006 and the survey remained accessible until

February 1, 2007.

All respondents were asked to identify additional experts; they identified 387 experts,

20 of whom were sent information and a link to the survey directly. The e-mail

addresses given for 10 were incorrect, so the investigator sent e-mails and/or voicemails

to their agencies. The remaining eight were already contacted in the initial wave.

To be included, participants self-identified as either a published expert in CIT or a

CIT co-ordinator/officer (program or state level). In addition, participants were

excluded if they did not rate the following items as ‘‘important’’ or ‘‘very important’’:

(2) pre-booking, (22) specialized officers and (42) specialized crisis response site. This

criterion ensured participants’ conceptualization of CIT was consistent with the

seminal literature (Cochran, Deane, & Borum, 2000; Dupont & Cochran, 2002).

Procedures

The investigators sent a description of the study and a link to the anonymous survey to

participants; this information was also placed on the LISTSERVs. A month after

contacting the last wave, a reminder e-mail was sent to all previously contacted experts.

Table 1. (Continued)

CIT elements Source

49. Easy access to medical treatment 6, 7, 17 Mental health/criminal justice collaboration 50. Involvement in program development 3, 4, 8, 17 51. Boundary spanner 1, 6, 9 52. Mutual respect 6, 8, 14 53. Communication 7, 8, 16 54. Stakeholder meetings 13, 16 55. Ride-alongs 6,7,16 56. Persons with mental illness and family involvement 7,8,16, 17

1, Borum et al. (1998); 2, Borum (2000); 3, Cochran et al. (2000); 4, Dupont & Cochran (2000); 5, Steadman et al. (2000); 6, Steadman et al. (2001); 7, Dupont & Cochran (2002); 8, el-Mallakh, Wulfman, Smock, & Blaser (2003); 9, Hails & Borum (2003); 10, Lattimore et al. (2003); 11, Perez et al. (2003); 12, Broner et al. (2004); 13, Ohio CIT Coordinators Committee (2004); 14, Reuland (2004); 15, Strauss et al. (2005); 16, Florida CIT Coalition (2005); 17, Teller et al. (2006).

Crisis Intervention Team model of jail diversion 85

Measures

The current study utilized an online survey posted on www.SurveyMonkey.com that

included screening/background questions (available from the author) and questions

regarding the importance and implementation of potential elements of the CIT model

derived in Study 1. We included distracter items in order to avoid over-agreement

(Marty et al., 2001).

Participants rated elements on their importance using a seven-point scale (ranging

from 1, extremely unimportant, to 7, extremely important). Next, participants were

presented with the full list of elements and asked to select the 10 ‘‘most critical’’ ones.

Finally, CIT officers/co-ordinators were asked to rate the degree to which they believe

their CIT program implemented each element (1, not implemented; 2, somewhat

implemented; 3, fully implemented).

Analyses

The investigator used SPSS 14.0 for Windows for all analyses. ANOVAs were

calculated to determine differences between referral sources on importance ratings of

each item. Intraclass correlations were calculated to determine inter-rater agreement

both for importance ratings overall and within each category. Items rated by 50% or

more of participants as ‘‘very important’’ were considered critical (McGrew & Bond,

1995).

Results

Sample

One hundred and thirty-four people from 29 states accessed the survey. Forty-four did

not fully complete it and one participant gave invalid data. Respondents were excluded

from the final sample for the following reasons: did not rate items 2, 22, or 42 as

‘‘important’’ or ‘‘very important’’ (n ¼ 14); they were not CIT co-ordinator/officers, published experts, or statewide CIT coordinators (n ¼ 13); or both (n ¼ 8).

Regarding rate of response, 59 out of 164 (36.0%) experts contacted completed the

survey; 35 (21.3%) were included in the final sample. Response rates cannot be

calculated for experts responding to the two LISTSERVs. However, 31 out of

64 (48.4%) participants from these sources accessing the survey completed it, and

20 (17.2%) were included in the final sample. Characteristics of the final sample

(n ¼ 55) can be seen in Table 2 and setting of the CIT program in Table 3.

Critical elements analyses

Thirty-six elements met the critical criterion (Table 4); the inter-rater reliability was

high for all 56 items (r ¼ 0.89, F(44, 2420) ¼ 8.79, p < .001). Importance ratings of non-distracter items (M ¼ 6.40, SD ¼ 0.39) was compared with distracter items (M ¼ 5.24, SD ¼ .92; t(54) ¼ 10.93, p < .001) – distracter items were rated as less important than non-distracter items. Items were grouped into three categories:

86 A. B. McGuire and G. R. Bond

organization and collaboration, law enforcement (with its three subcategories of officer

selection, officer training, and officer roles), and mental health services. Inter-rater

reliability within each category was: organization and collaboration [r ¼ 0.76, F(48, 720) ¼ 4.12, p < .001], law enforcement [r ¼ 0.80, F(50, 1350) ¼ 4.90, p < .001], and mental health services [r ¼ 0.76, F(50, 600) ¼ 4.07, p < .001]. The respective categories

Table 2. Sample characteristics

Variables M (SD)/n (%)

Age a

45.33 (8.85) Years in law enforcement

b 17.31 (9.24)

Years in jail diversion b

4.62 (5.63) Recruitment source Invited 31 (56.4%) NAMI 14 (25.5%) Consensus project 6 (10.9%) Snowball 4 (7.3%)

Highest degree a

High school/GED 7 (13.0%) Associates 7 (13.0%) Bachelors 21 (38.9%) Graduate 19 (35.2%)

Type of expert CIT author/researcher 8 (14.5%) CIT program co-ordinator/officer 35 (63.6%) Both 12 (21.8%)

Jail diversion co-ordinator 5 (9.1%) Researcher/academician 5 (9.1%) Police officer 32 (58.2%) Mental health practitioners 10 (18.2%) Administrator 8 (23.5%) Other job 16 (29.1%) Primary employment setting Police/sheriff’s office 39 (70.9%) Mental health treatment facility 4 (7.3%) College/university 1 (1.8%) Other 11 (20.0%)

n ¼ 55. a n ¼ 54. bn ¼ 42. CIT, Crisis Intervention Team; GED, General Educational Development; NAMI, National Alliance on Mental Illness.

Table 3. Characteristics of Crisis Intervention Team (CIT) jurisdictions

Variables M (SD)/n (%)

Setting Urban 31 (68.9%) Small city 14 (31.1%)

Years since first CIT training a

4.32 (3.81) Years since 24/7 CIT coverage

b 3.73 (3.27)

Division Patrol 21 (72.4%) Special operations 1 (3.4%) Training 1 (3.4%) Mental health agency 0 (0.0%) Other 6 (20.7%)

a n ¼ 44. bn ¼ 22.

Crisis Intervention Team model of jail diversion 87

did not differ in the percentage of items within the category reaching criticality: 10

(66.7%), 16 (57.1%), and 10 (76.9%) [x 2 (2) ¼ 1.56, p ¼ .46].

Implementation

Analyses of level of element implementation were limited to participants who were

affiliated with a specific CIT program; 44 of the 48 affiliated participants rated

implementation. Investigators considered items with a mean rating of two or greater

‘‘implemented’’ (n ¼ 39, 69.6%). Thirty-three out of 36 (91.7%) critical items met the

Table 4. Items rated ‘‘very important’’ by � 50% of sample No. Item n (%)

Philosophy and collaboration 1 Program coordinator 36 (65.5%) 2 Pre-booking 36 (65.5%) 4 Jail is avoided 32 (58.2%) 6 Treatment mandated (distracter) 30 (54.5%) 50 Involvement in program development 45 (81.8%) 51 Boundary spanner 39 (70.9%) 52 Mutual respect (interagency) 42 (76.4%) 53 Communication (interagency) 43 (78.2%) 54 Stakeholder meetings 38 (69.1%) 56 Persons with mental illness and family involvement 35 (63.6%) Officer roles/services Officer selection 9 Voluntary service 28 (50.9%) Officer training 14 Intensive training 49 (89.1%) 15 Training for dispatchers 31 (56.4%) 17 De-escalation training 46 (83.6%) 18 Persons with mental illness and family member trainers 38 (69.1%) 19 Mental health provider trainers 42 (76.4%) 20 Practical training 40 (72.7%) Officer roles 22 Specialized officers 40 (72.7%) 25 CIT officers function as a team 30 (54.5%) 26 On-Scene disposition 41 (74.5%) 27 CIT officer is designated officer in charge on mental health calls 30 (54.5%) 28 CIT officer responds to all mental health calls 33 (30.0%) 30 24/7 coverage (CIT officers) 39 (70.9%) 31 De-escalation 48 (87.3%) 32 Transport to crisis center 33 (60.0%) 36 Command staff committed to effective response 44 (80.0%) Mental health services 37 Rapid transfer of responsibility 47 (85.5%) 38 Legal grounds for detention 37 (67.3%) 39 No-refusal policy 44 (80.0%) 40 Crisis line 40 (72.7%) 41 Referral to outpatient community providers 33 (60.0%) 42 Specialized crisis response site 41 (74.5%) 43 Services available 24 hour/7 days a week (mental health) 48 (87.3%) 44 Single point of entry 30 (54.5%) 47 SCRS is a secure facility 32 (58.2%) 49 Easy access to medical treatment 33 (60.0%)

a Number (%) rating as ‘‘very important’’. CIT, Crisis Intervention Team.

88 A. B. McGuire and G. R. Bond

criterion for implemented (Table 5); six out of 20 (30.0%) non-critical items met the

criterion for implemented (Table 6) [x 2 (1) ¼ 23.13, p < .001]. Critical items received

higher implementation ratings (M ¼ 2.42, SD ¼ 0.35) than non-critical items [M ¼ 1.87, SD ¼ 0.28; t(43) ¼ �15.28, p < .001]. The average implementation rating across both critical and non-critical items indicated that non-distracter items had higher

implementation ratings on average (2.41, SD ¼ 0.32) than distracter items [1.62, SD ¼ 0.32; t(44) ¼ �15.83, p < .001].

Level of implementation related to years since the agency first established 24/7 CIT

coverage (r ¼ 0.52, p ¼ .02, n ¼ 19). Conversely, respondent characteristics were not related to rating of implementation: age (r ¼ �0.18, p ¼ .24, n ¼ 43), years in law enforcement (r ¼ �0.14, p ¼ .41, n ¼ 38), and years in jail diversion (�0.12, p ¼ .48, n ¼ 37). The percentage of implemented items did not differ by category: organization and collaboration (n ¼ 10, 66.7%), law enforcement (n ¼ 21, 75.0%), and mental health services [n ¼ 8, 61.5%; x2(2) ¼ 0.85, p ¼ .66).

Table 5. Implementation of critical items

Implementation

High Low

1. Program co-ordinator 6. Treatment mandated (distracter) 2. Pre-booking 44. Single point of entry 4. Jail is avoided 47. SCRS is a secure facility 9. Voluntary service 14. Intensive training 15. Training for dispatchers 17. De-escalation training 18. Persons with mental illness and family member trainers 19. Mental health provider trainers 20. Practical training 22. Specialized officers 25. CIT officers function as a team 26. On-scene disposition 27. CIT officer is designated officer in charge on mental health calls 28. CIT officer responds to all mental health calls 30. 24/7 coverage 31. De-escalation 32. Transport to crisis center 36. Command staff committed to effective response 37. Rapid transfer of responsibility 38. Legal grounds for detention 39. No-refusal policy 40. Crisis line 41. Referral to outpatient community provider 42. Specialized crisis response site 43. Services available 24 hour/7 days a week 49. Easy access to medical treatment 50. Involvement in program development 51. Boundary spanner 52. Mutual respect 53. Communication 54. Stakeholder meetings 56. Persons with mental illness and family involvement

Critical items determined by more than 50% or respondents rating as ‘‘Very Important.’’ Implementation is divided as such: high elements with mean of ‘‘2- partially implemented’’ or higher. CIT, Crisis Intervention Team.

Crisis Intervention Team model of jail diversion 89

DISCUSSION

This study identified a preliminary list of 36 elements of the CIT model with expert

agreement regarding their importance. Elements were grouped into the following

categories: philosophy and collaboration, law enforcement, and mental health services.

In general, experts viewed these items not only as important, but also as implemented.

Elements

Philosophy and collaboration

The philosophy and collaboration elements dealt with the guiding vision and

infrastructure of a CIT program. CIT is a pre-booking diversion program – diversion

takes place before a person is arrested and/or placed in a criminal justice facility

(Steadman, Morris, & Dennis, 1995). We used importance ratings of this element as an

inclusion criterion because it is so defining of the CIT program (Dupont & Cochran,

2002; Steadman et al., 2001)

Experts in the current study and other efforts (Council of State Governments, 2007)

highlighted the importance of collaboration across agencies and stakeholder groups. All

stakeholders must communicate, be involved from program inception, and maintain an

attitude of mutual respect. Experts in the current study affirmed Steadman’s (1992) call

for a ‘‘boundary spanner’’ who is charged with facilitating this collaboration.

Philosophical differences between stakeholder groups present challenges, though.

For instance, the inclusion of mandated treatment is at odds with some stakeholders’

‘‘recovery’’-oriented philosophy (Frese, Stanley, Kress, & Vogel-Scibilia, 2001).

Results also highlight the need for leadership. CIT programs need a program co-

ordinator. Extant literature on implementation of evidence-based practices emphasizes

the importance of a program coordinator (Torrey, Finnerty, Evans, & Wyzik, 2003).

Table 6. Implementation of non-critical items

Implementation

High Low

7. Diversion for minor offenses 3. Post-booking diversion (distracter) 10. Formal selection process 5. Charges avoided or reduced 11. Officer’s record 8. Court-based diversion (distracter) 12. Experienced officers 13. Psychological testing (distracter) 24. Specialized officers maintain patrol duties 16. Department-wide training (distracter) 35. Leadership within agency 21. Cross-training

23. Mental health officers (distracter) 29. Specialized unit (distracter)

33. Role in civil commitment process 34. CIT officers serve jails/prisons (distracter)

45. Secure transportation 46. Ambulance service

48. No productivity standard 55. Ride-alongs

Critical items are determined by more than 50% or respondents rating as ‘‘very important.’’ Implementation is divided as follows: high elements with mean of ‘‘2, partially implemented’’ or higher.

90 A. B. McGuire and G. R. Bond

Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004) also emphasize the need

for a ‘‘champion’’. Although these two roles can overlap, the former indicates an

instrumental role, whereas the latter is a social and philosophical motivator.

In contrast to the seminal literature (Dupont & Cochran, 2002), experts in the

current study did not agree on diversion being limited to minor offenses. Consistent

with this, empirical evidence supports the successful diversion of people with more

serious (e.g., violent) charges (Naples & Steadman, 2003). Also, although the published

literature states that charges should be reduced or dropped (Lattimore, Broner,

Sherman, Frisman, & Shafer, 2003; Perez, Leifman, & Estrada, 2003; Steadman et al.,

2000), experts in the current study did not agree. Finally, experts did agree that

treatment should be mandated. What emerges is a model intended to forcefully place

people with mental illness in treatment, rather than assist in maintaining them in the

community.

Law enforcement

Law enforcement elements clarify how officers are selected for CIT duty, CIT training,

and the roles and responsibilities of CIT officers. These elements represent the largest

proportion of items culled from the literature in Study 1 and those reaching agreement

in Study 2. Their over-representation points to the disproportionate attention law

enforcement elements receive over mental health services. Elements regarding CIT

officers’ roles and responsibilities indicate the importance of specialized CIT officers

who are available 24/7 to de-escalate situations involving mental illness and dispose the

cases appropriately.

Regarding training, experts specified the importance of training being intensive,

practical, and provided to CIT officers and call-takers. These findings are consistent

with the Consensus Project’s list of essential elements (Council of State Governments,

2007). Regarding training content, one item that bears comment is de-escalation. First,

anecdotally, the investigator observed several agencies claiming to be a ‘‘CIT’’ program

that have only de-escalation training and/or training on mental illness. For instance,

some correctional facilities provide ‘‘CIT training’’ for their correctional officers. These

programs differ from programs including co-ordinated efforts between criminal justice

and mental health treatment settings. Secondly, although crisis de-escalation is popular

in the literature and the experts in the current study endorsed its importance, the scant

and outdated literature regarding training in crisis de-escalation does not support its

effectiveness (Lieberman & Schwartz, 1973; Mulvey & Reppucci, 1981).

Regarding the target population for training, two issues arise. Consistent with both

the literature and specialist model of CIT, experts did not endorse department-wide

training as critical. However, respondents from non-urban areas rated this item higher

(M ¼ 5.93, SD ¼ 1.21) than respondents in urban areas [M ¼ 4.71, SD ¼ 2.13; t(41) ¼ - 2.44, p ¼ .02); this split is consistent with the Ohio formulation of CIT (Ohio CIT Committee, 2004).

In contrast, training for call-takers was considered important in the current study and

has been included in other formulations of CIT (Ohio CIT Committee, 2004; Reuland,

2004; The Florida CIT Coalition, 2005; Council of State Governments, 2007) despite

its absence in seminal articles regarding CIT. Call-takers triage calls and represent a

crucial juncture at which a CIT officer will or will not be dispatched. Future research

Crisis Intervention Team model of jail diversion 91

will need to clarify training content for call takers and develop screening tools to triage

calls appropriately.

Mental health services

Mental health service elements dealt mostly with the SCRS. Elements dealt with

making services available, expedient, and easy to use for CIT officers. Few items dealt

with mental health services beyond the immediate crisis point. A similar result is found

in the Consensus Project list of essential elements (Council of State Governments,

2007). Although follow-up mental health services may be viewed as outside the scope of

CIT, quality outpatient services may aid in decreasing criminal justice involvement and

allay mental health service costs associated with CIT (Cowell, Broner, & Dupont,

2004). Future research should ask: ‘‘To what services do CIT officers refer and what

happens to these consumers after the immediate crisis?’’

Limitations

In Study 1, only a few select experts were included, although these experts did provide

valuable feedback. Also, we limited the literature review to published sources. A wealth

of relevant literature likely exists in procedural manuals, training manuals, guidebooks,

and other documents developed and maintained by specific CIT programs. None-

theless, published literature represents the collective knowledge of experts in the field

and is widely accessible to all stakeholders.

Criminal justice experts were over-represented in Study 2, which likely contributed

to the over-representation of criminal justice elements meeting criticality. The emphasis

on criminal justice may be a natural outgrowth of CIT criminal justice origins, though.

Nonetheless, this bias limits the conclusions one can draw regarding the mental health

components of an effective CIT program. Finally, this study’s inclusion criteria

eliminated a large proportion of respondents from analyses. The criteria, however,

provided a more focused examination of CIT as originally formulated. Although

adaptation of a model is natural and necessary, this study sought to clarify the initial

explication.

Finally, although the importance and implementation ratings of non-distracter items

was higher than distracter items, the ratings for distracter items were still in the

‘‘important’’ and ‘‘partially implemented’’ range. This may be reflective of an acquiesce

bias and/or an actual tendency for experts to endorse elements of other models instead

of exclusively focusing on CIT.

Summary and Conclusions

The 36 elements identified in the current study are common in the literature and agreed

upon by experts as both important and implemented by their programs. We grouped

these items into three categories: philosophy and collaboration, law enforcement, and

mental health services.

92 A. B. McGuire and G. R. Bond

The identification of the critical elements of a model is a process inextricably

embedded within a larger model development process (Bond et al., 2000; Mowbray

et al., 2003). Experts suggest that an element should only be considered critical if it has

‘‘obtained a significant correlation with a criterion measure’’ (Bond et al., 2000, p. 11)

and thus can ‘‘account for positive changes in the lives of consumers’’ (Greenhalgh

et al., 2004, p. 597). Given this context, when interpreting the results of the current

study, one should be mindful of the equivocal state of the empirical evidence regarding

jail diversion in general and CIT more specifically (Hartford et al., 2006). Furthermore,

the inadequate empirical research, as well as the rapid spread of jail diversion without

clear measures of fidelity to circumscribed, well-defined models, confuses efforts to

disentangle the ‘‘hard core’’ (i.e., critical elements) of a particular model from the ‘‘soft

periphery’’ of practices that are recommendable for any jail diversion program

(Greenhalgh et al., 2004, p. 597).

The current study should be considered a first effort at enumerating the elements of

CIT. They should not, however, be considered the last word on the critical elements of

the model, as a good deal of further research is necessary to: (a) develop true consensus

(e.g., through the use of an expert panel); (b) examine the association between these

elements and outcomes; and (c) differentiate these elements from elements common to

all quality jail diversion efforts.

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94 A. B. McGuire and G. R. Bond

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